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SZL\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING •
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^ _= l • CLIMWr1-1 , Mass. Date e-/7 242.11...L Permit # 111
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Building Location
' S,,_ SFFE2glad 11) Owner's Name OtA2alG{v aT I UPIt4-:
- 9)OL` l.I 4AtMWT1-4 Type of Occupancy -- ES CO FgiJt1144•,_
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. New . Renovation ❑ Replacement 0 • Plans Submitted: Veep No
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Installing Company Name Rusty' s Inc. eck'one: Certificate _
Address 222 Mid-Tech Drive le Corporation 1762-r
•• West Yarmouth ❑, partnership ,
Business Telephone 508-775-1903 0 Firm/Co.
Name of Licensed Plumber or•Gas FitterFrank W. Roderick •_
INSURANCE COV RAGE: •
• I have a current ' bility Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. .
Yes No ❑
it you have checked yes, Tease indicate the type coverage by checking the appropriat: P.A.
A liability Insurance policy Other type of Indemnity❑ • Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by '
Chapter 142 of the Mass. General Laws• and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent 0
Signature of Owner or Owner's Agent
thereby certify that all of the details and Information I have submitted (or entered)In above application are true and accurate to the best of my
•knowledge and that all plumbing work and installations performed under the permit i ued for this application will be in ccmplianm with all
pertinent provisions,o`the Massa rusetts State,Gas Code and,Chapter 142 of tine •-'neral Laws.,-.- --.1 rile. ✓fftt. -r_ .-.._ '. _
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Plumber i gnature of cense^ Plumber,al as ILet I i 1 i I
Title -... ,
iter i License Number 7794 r
• PF BD(OFFICE USE ONLY) bu,meyrnan
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